Volunteer Media release

Consent for use of donor image

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As the legal representative for [NAME OF DONOR ENTERED BELOW] , I hereby consent to the use of his/her name and likeness for the sole purpose of promoting organ and tissue donation. I understand that the use of his/her name and likeness may include, but not be limited to photographs, video, newspaper articles, brochures, displays, television, radio, digital platforms (i.e. social media, websites, etc.) or any other public community relations material. I hereby acknowledge that this authorization is volunteered without obligation of any kind on the part of Lifesharing, partners, their employees, and designated agents. This authorization is given without hope or expectation of reward or compensation of any kind. I hereby waive my right to inspect or approve any materials which may from time to time be created by Lifesharing and partners, which may include his/ her name, image, photo, likeness or voice. I, together with my heirs, assigns, agent, guardians, and legal representatives hereby release Lifesharing and partners from any and all claims, liabilities, and losses that may arise from its use of his/her name image, photo, likeness and voice.

Name of Donor*

Contact Information

Name*
Address*
Please include any other important information here. If signing on behalf of a minor under your legal custody, please include their full name.

Electronic Signature of Next-of-Kin/Legal Representative

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